Journal of Functional Morphology and Kinesiology Article Arthrocentesis and Sodium Hyaluronate Infiltration in Temporomandibular Disorders Treatment. Clinical and MRI Evaluation Mario Santagata 1, Roberto De Luca 2, Giorgio Lo Giudice 2,*, Antonio Troiano 2, Giuseppe Lo Giudice 3 , Giovanni Corvo 1 and Gianpaolo Tartaro 1 1 Multidisciplinary Department of Medical-Surgical and Dental Specialities, Oral and Maxillofacial Surgery Unit, AOU University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy; [email protected] (M.S.); [email protected] (G.C.); [email protected] (G.T.) 2 Maxillofacial Surgery Unit, Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples "Federico II”, 80138 Naples, Italy; [email protected] (R.D.L.); [email protected] (A.T.) 3 Department of Biomedical and Dental Sciences and Morphofunctional Imaging, Messina University, 98122 Messina, Italy; [email protected] * Correspondence: [email protected]; Tel.: +393472507395 Received: 16 January 2020; Accepted: 28 February 2020; Published: 6 March 2020 Abstract: Arthrocentesis in temporomandibular joint disorders can be associated with the intra-articular infiltration of various drugs with the objective of increase treatment efficacy. The aim of this study was to evaluate the clinical indexes variation in patients affected by temporomandibular joint disorders treated with arthrocentesis and sodium hyaluronate (SH) injections. A total of 28 patients suffering from temporomandibular joint disorders underwent one cycle of five arthrocentesis and infiltrations of sodium hyaluronate. Spontaneous mouth opening improved from 36.3 7.5 mm ± to 45.1 1.9 mm at six months follow-up. A significant reduction in the pain at rest and during ± mastication mean values emerged at follow-up (p < 0.0001). The mean masticatory efficiency, evaluated through a visual analogic scale, showed improvement at the follow-up period, highlighted by the increase of mean value from a baseline of 3.1 1.2 to a mean value of 8.5 1.2 (p < 0.0001). The mean ± ± severity of the joint damage at baseline time was 2.4 0.9 and decreased to 0.4 0.3 at the end of ± ± the follow-up period. The decrease in values is confirmed by statistical test (p < 0.05). Our data show how arthrocentesis integrated with sodium hyaluronate infiltrations performed under local anesthesia is a valid method of treating temporomandibular joint disorders. Keywords: TMJ; temporomandibular joint disorders; arthrocentesis; sodium hyaluronate; hyaluronic acid 1. Introduction Temporomandibular joint (TMJ) disorders include disc displacement and degenerative and/or inflammatory pathologies. The TMJ accounts for about 10% of the population with a predilection for female sex and is often associated with chronic pain and limited function resulting in decreased quality of life for the patient [1–4]. Different conservative and surgical treatments have been studied to restore stomatognathic function and improve clinical symptoms [5–7]. Conservative treatments include behavioral therapy, administration of non-steroidal anti-inflammatory drugs and corticosteroids, bite splints, botulinum toxin injections, and physical therapy [8–13]. J. Funct. Morphol. Kinesiol. 2020, 5, 18; doi:10.3390/jfmk5010018 www.mdpi.com/journal/jfmk J. Funct. Morphol. Kinesiol. 2020, 5, 18 2 of 8 An alternative in surgical treatments is arthrocentesis: it is a minimally invasive procedure, commonly used to remove inflammatory mediators associated with nociceptive processes within the synovial fluid [14–16]. This procedure can be associated with the injection of various drugs, such as sodium hyaluronate (SH) with the objective of increasing treatment efficacy [17,18]. SH is a physiological component of synovial fluid in joints and performs a lubricant function. Its ability to retain water modifies the viscosity of the synovial fluid increasing the hydration, allowing mechanical shock resistance and overall cartilage stability. The therapeutic effect of this molecule had been exploited in orthopedics diseases reducing subchondral bone damage, chondrocyte apoptosis, cartilage inflammation, and overall cartilage deterioration. SH intra-articular infiltration in worn joints results in pain reduction and function improvement [19,20]. The aim of this study was to evaluate the clinical indexes variation in patients affected by temporomandibular joint disorders treated with arthrocentesis and SH injections. 2. Materials and Methods A total of 28 patients suffering from temporomandibular joint disorders (27 women and 1 man, age range: 16–69 years, mean age: 40,6 years) underwent a cycle of five arthrocentesis with injections (1 per week for 5 weeks) of 1 mL hyaluronic acid (Sinovial®Mini 0,8%, IBSA Farmaceutici Italia, Lodi, Italy) into both TMJs. The infiltrations were performed according to the protocol in use for degenerative knee pathology treatment [21–24]. The protocol was approved by the internal ethical committee of the University (AOU-SUN prot. 3731, 16 May 2015). Informed consents were signed before every procedure. Inclusion criteria were disc displacement without reduction with limited opening according to the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) classification system, TMJ pain at rest or evoked by palpation or forced mouth opening, functional limitation to opening movements, failure of conservative therapy alone (non-steroidal anti-inflammatory drugs and corticosteroids), and failure of gnathological treatment with occlusal bite [25,26]. Exclusion criteria were previous surgical treatments and arthrocentesis, intra-articular infiltration of drugs, Wilkes classification < 1 and > 4, and potential risk factors of SH allergic reactions. All patients underwent TMJ scans with Magnetic Resonance Imaging (MRI) before treatment (T0) and at 6 months follow-up (T1) in order to assess disc disorders, condylar cartilage erosions, and condylar excursion differences. The clinical parameters collection was performed, recording the data at the time of the diagnosis (baseline) and after 6 months from the end of the treatment. The clinical data collected were: Severity of the joint damage (assessed using Wilkes staging system for TMJ internal derangement • stages 0–5) [27]. Maximum non-assisted mouth openings (in mm). • Pain at rest and during mastication, assessed by means of a Visual Analogic Scale (VAS) from 0 to • 10, with the extremes “no pain” and “pain as bad as the patient ever experienced”, respectively [28]. Mastication efficiency, assessed by a VAS scale from 0 to 10, whose extremes were “eating only • semi-liquids” and “eating solid hard food”, respectively. The research was based on a comparison of changes in clinical parameters analyzed before and six months after the end of treatment. Demographic data are summarized in Table1 (Table1). Clinical parameter data at T0 and T1 are summarized in Table2 and Figure1. The instrumental analysis performed on TMJs at T0 and T1 is shown in Figure2. J. Funct. Morphol. Kinesiol. 2020, 5, 18 3 of 8 Table 1. Demographic and clinical data at enrollment. J. Funct. Morphol. Kinesiol. 2020, 5, 18 3 of 8 Characteristics Age, mean (years) Subjects Total 28 40.6 (16–69) Treatment tolerabilitySex (%) Male, N (%) Slight1 (3.5) 7.2 Female, N (%)Moderate27 (96.5) 46.4 Age, mean (years)Good 40.6 (16–69) 46.4 Clinical parameter data at T0 and T1 are summarized in Table 2 and Figure 1. Treatment tolerability (%) Slight 7.2 Moderate 46.4 Table 2. Clinical Gooddata at follow-up. 46.4 Indexes T0 T1 P (T0 vs Table 2. Clinical data at follow-up. T1) Maximum non-assisted mouth opening, mean ± SD 36.3 ± 45.1 ± < 0.05 Indexes T0 T1 p (T0 vs. T1) (millimeters) 7.5 1.9 < 0.05 Maximum non-assisted mouth opening, mean SD (millimeters) 36.3 7.5 45.1 1.9 <0.05 Severity joint damage, mean ± SD (Wilkes Score)± 2.4 ± ±0.9 0.4 ± 0.3± < 0.0001 Severity joint damage, mean SD (Wilkes Score) 2.4 0.9 0.4 0.3 <0.05 Pain at rest, mean ± SD (VAS± Score) 6.4 ±± 2.5 0.7 ± 0.5± < 0.0001 Pain at rest, mean SD (VAS Score) 6.4 2.5 0.7 0.5 <0.0001 ± ± ± PainPain duringduring mastication, mastication, mean mean SD± SD (VAS (VAS Score) Score) 8.1 8.1 ± 1.71.7 0.9 0.9 ± 0.60.6 < 0.0001<0.0001 ± ± ± MasticationMastication e ffiefficiency,ciency, mean mean SD± SD (VAS (VAS Score) Score) 3.1 3.1 ± 1.21.2 8.5 8.5 ± 1.21.2 <0.0001 ± ± ± Figure 1. Figure 1. GraphicalGraphical representation representation of collected of collected data dataat baseline at baseline (T0) and (T0) 6 months and 6months follow-up follow-up (T1). (A) (T1). (A)MaximumMaximum non-assisted non-assisted mouth mouth opening opening in mm. in (B) mm. Joint(B) damageJoint severity damage expressed severity expressedin Wilkes Score. in Wilkes Score.(C) Pain(C) atPain rest at expressed rest expressed in the in Visual the Visual Analogic Analogic Scale Scale(VAS) (VAS) Score. Score. (D) Pain(D) Painduring during mastication mastication expressedexpressed inin VASVAS Score. (E)(E) MasticatoryMasticatory efficiency efficiency expressed expressed in inVAS VAS Score. Score. The instrumental analysis performed on TMJs at T0 and T1 is shown in Figure 2. J. Funct. Morphol. Kinesiol. 2020, 5, 18 4 of 8 J. Funct. Morphol. Kinesiol. 2020, 5, 18 4 of 8 FigureFigure 2. 2.Right Right TMJ TMJ MRI MRI in in sagittal sagittal planeplane of patient with with the the jaw jaw closed closed at atT0 T0 (A ()A and) and T1 T1(B) ( andB) and open open at T0at T0 (C ()C and) and T1 T1 (D (D).). Increased Increased disk disk andand cartilagecartilage thickness thickness (blue (blue arrows) arrows) and and increased increased excursion excursion of of mandibularmandibular condyle condyle (red (red arrows) arrows) were were observed.observed. BAR == 11 cm cm 2.1. Clinical Procedure 2.1. Clinical Procedure ArthrocentesisArthrocentesis of of upperupper jointjoint spacespace was performed under under local local anesthesia anesthesia with with 20 20mg/mL mg/mL ® MepivacaineMepivacaine HydrochlorideHydrochloride (Carbocaine® (Carbocaine 2%2% Aspe Aspenn Pharma Pharma Trading Trading Limited, Limited, Dublin DublinIE).